Mark E. Williams, M.A., LCMHC
186 White Street
South Burlington, VT 05403-5940
Phone: 802-865-4883
Fax: 802-488-5653
markewilliams@gmail.com


OBTAINING & RELEASING INFORMATION 


I, _________________________, (name of client) hereby authorize Mark Williams to obtain and release information pertaining to my evaluation and treatment to and from:




for the purpose of:  




I understand that authorization shall remain valid from the date of my signature below and ending on: 


I have been informed that I may revoke this authorization by written communication. 


I certify that this form has been fully explained to me and that I understand its contents.


____________________________                             __________________
Signature of Client                                              Date of Authorization